Provider Demographics
NPI:1316228000
Name:MAGALLANEZ, ROBERTO MIGUEL (LCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:MIGUEL
Last Name:MAGALLANEZ
Suffix:
Gender:M
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 E 10TH ST # 4-156
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-7285
Mailing Address - Country:US
Mailing Address - Phone:812-624-1180
Mailing Address - Fax:
Practice Address - Street 1:3310 E 10TH ST # 4-156
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-7285
Practice Address - Country:US
Practice Address - Phone:812-624-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50741041C0700X
IN34007166A1041C0700X, 101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300062432Medicaid